Australian attitudes to early and late abortion

Objective: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.

Design, setting and participants: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008.

Results: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.

Conclusions: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Victorian abortion laws were reformed in October 2008 following a review by the Victorian Law Reform Commission.1 The laws in New South Wales, South Australia and Queensland are similar to the old Victorian laws which were criticised as being obsolete and unclear.1,2 Recently, there has been debate on abortion law reform in both Queensland and New South Wales.3,4

Previous surveys of community attitudes to abortion5-7 have several limitations.1 It is unclear what proportion of those who support the right to access abortion believe that it should be restricted on the basis of factors such as gestational age and women’s reasons for seeking abortion.1 Europeans tend to support women’s access to abortion;8 Americans are more likely to oppose it.9

Late abortion is especially controversial, although less than 2% of abortions occur at 20 weeks or later.10,11 Few data support the belief that Australians strongly oppose women’s access to late abortion,12 while surveys in the United Kingdom13 and United States14 do report opposition.

Given the limitations of existing data, community views may be misinterpreted in public debate about abortion law reform. We conducted a survey of Australian attitudes to abortion, including late abortion, during mid 2008.

Methods

An online survey of Australian adults was conducted between 28 and 31 July 2008. The target population was defined as all Australian residents aged 18 years or older. Oversampling was used in Victoria so that more statistically accurate results could be gained for Victoria, in light of its pending abortion law reforms. To provide representative national results, the oversample for Victoria was weighted to reflect (in addition to other demographic criteria) the proportion of the Australian population residing in Victoria.

The survey was conducted by a private market research organisation (Crosby Textor, Sydney, NSW) with experience in measuring public opinion on health and medical issues. An online panel of more than 500 000 recruited participants (PermissionCorp, Sydney, NSW) was used as a representative sample frame for this study. Participants on this panel elect to either receive awards points or participate in a prize draw in return for completing a survey. A random sample (stratified by age, sex and location) was invited to participate, provided with a short preamble regarding the subject matter of the survey, and then asked for their consent to participate.

Respondents were asked to confirm their background information, such as age, sex and location, and provided with factual information about the proposed law change in Victoria. They were then asked about their views on abortion. To avoid invalid or prompted answers, respondents were not permitted to revise previous answers once they had proceeded to a new question. The questionnaire was tested before full online launch, and standard quality control procedures were applied.

The survey data were weighted15,16 by sex, age and location according to the latest available data from the Australian Bureau of Statistics;17 notably, the oversample for Victoria was weighted to reflect actual population proportions of sex, age and location. The weighted population breakdown was as follows:

Sex: male, 49%; female, 51%

Age: 18–19 years, 4%; 20–24 years, 9%; 25–29 years, 10%; 30–34 years, 9%; 35–39 years, 11%; 40–44 years, 9%; 45–49 years, 10%; 50–54 years, 9%; 55–59 years, 8%; 60–64 years, 7%; ≥ 65 years, 14%

Weighted frequencies and cross-tabulations were then used to produce results as percentages. A summary of the results has been reported elsewhere.18

In accordance with the National Health and Medical Research Council National statement on ethical conduct in human research,19 ethics approval was not sought because the survey was anonymous and followed procedures that are usual for public opinion surveys.

Results

Four per cent of individuals who were invited to participate in the survey declined, and 15% of started surveys were not completed. Of the 1050 respondents who completed the survey, 526 resided in Victoria and 524 resided in other states and territories. After weighting the oversample for Victoria, the effective national sample size was 798.15 Weighting factors other than that relating to location fell within acceptable margins (0.96–1.04).

The maximum margin of error for this effective national sample size of 798 is a ± 3.5 percentage point confidence interval20 in 95 of 100 cases (at the 95% confidence level)21 with results of about 50%. Margins of error are smaller for results further from 50%, but may increase for analyses of subsamples. For example, the effective oversample for Victoria of 523 has a maximum margin of error of ± 4.3 percentage points in 95 of 100 cases with results of about 50%, and the effective sample for other states and territories of 505 has a maximum margin of error of ± 4.4 percentage points in 95 of 100 cases with results of about 50%.

Attitudes to abortion

Eighty-seven per cent of respondents indicated that abortion should be lawful in at least some circumstances in the first trimester; 69% indicated this for the second trimester and 48% for the third (Box 1).

In a wide range of clinical and social circumstances, a majority of respondents indicated that doctors should not face professional sanctions for terminating a pregnancy after 24 weeks’ gestation (Box 2). In no circumstance did a majority indicate that a doctor should be sanctioned for terminating a pregnancy after 24 weeks’ gestation. Of the subgroup of respondents who indicated that termination of pregnancy in the third trimester should be unlawful, a majority indicated that doctors should not be sanctioned for terminating a pregnancy after 24 weeks’ gestation in six of the 16 circumstances described in Box 2. In the same subgroup, there was majority support for professional sanctions in five of the 16 circumstances.

There were no statistically significant differences between the responses, regarding attitudes to both lawfulness of abortion in each trimester and to sanctions in the various circumstances, of respondents who resided in Victoria and those who resided in any part of Australia (differences, 0–4 percentage points; maximum CI, ± 2.5–4.3 percentage points), nor between men and women (differences, 0–4 percentage points; maximum CI, ± 2.9–4.4 percentage points). Seventeen per cent of women indicated they had personally had a pregnancy termination, and these women were more likely to oppose sanctions than the female population generally (ie, all women, regardless of whether they had had an abortion) (differences, 6–20 percentage points; maximum CI, ± 6.9–11.5 percentage points). Respondents aged 45 years and older were more likely to oppose sanctions than those aged 18–44 years (differences, 2–12 percentage points; maximum CI, ± 4.3–5.0 percentage points). Respondents who nominated a religious affiliation were slightly more likely to support sanctions than those who reported no religion (differences, 2–10 percentage points; maximum CI, ± 3.4–6.6 percentage points).

Our survey shows a high level of support for access to early abortion: 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). There was little support for professional sanctions against doctors for providing terminations after 24 weeks’ gestation. When asked to consider specific, realistic situations in which late abortion might be considered, many respondents opposed sanctions against doctors, particularly when abortion is sought because of maternal or fetal complications rather than personal reasons. Respondents with a religious affiliation were slightly less likely to oppose sanctions than those without a religious affiliation.

Public opinion research can have a major impact on government policy and, therefore, on access to quality medical care. Although results of such research are quoted widely in medical literature, they are not usually peer reviewed. To our knowledge, our study is the first detailed survey of Australian attitudes to late abortion that includes attitudes in various clinical and social situations. Our findings challenge the belief that Australians strongly oppose women accessing late abortion.12

Limitations of our study include that it is cross-sectional at a single time point and small. Although the margins of error were small, these apply only to measuring a proportion based on the total sample. However, the sample size was sufficient to enable a high level of confidence, which makes the data generalisable to the Australian population. The 4% opt-out rate in our study minimised potential sample bias, and the 15% drop-out rate was not unusual for this data collection method.

Online data collection might be replacing paper-and-pencil surveys in academic research.22 It enables more candid and considered answers to highly personal and potentially confronting issues. Potential problems associated with online survey research, many not unique to this approach,22 include the use of volunteer sampling rather than probability sampling, the possibility that respondents are not representative of the target population, and the fact that not everyone has internet access. However, there is no conclusive evidence that responses differ between mail and online surveys,23 and data collected online may be more complete.24

Previous surveys in Australia5-7 have not usually specified the gestational age at which an abortion is performed. In the 2003 Australian Survey of Social Attitudes, 81% of respondents agreed or strongly agreed that a woman should have the right to choose whether or not she has an abortion; 9.4% disagreed or strongly disagreed.5 In the 2004 Australian Election Study,89% of respondents said that women should be allowed to have an abortion, either readily when they want one (54%) or in special circumstances (35%); only 4% said abortion should not be allowed under any circumstances.6 In contrast, the Australian Federation of Right to Life Associations survey7 found that only 6% of respondents agreed with allowing abortion after 20 weeks’ gestation. Problems with the latter survey may have resulted in bias.1

Our data suggest that single general questions, as used in previous surveys, provide a limited view of community sentiment, as has previously been noted.1Simple yes/no polls do not allow people to accurately express the subtlety of their views in the complex range of clinical and social situations in which access to abortion might be sought. For example, although 48% of respondents indicated that abortion in the third trimester of pregnancy should be unlawful, less than a quarter indicated that a doctor should face professional sanctions for performing termination after 24 weeks’ gestation when there is a risk to the physical or mental health of the woman or baby.

Respondents were more equivocal about sanctions in scenarios regarding late termination for reasons relating to the preferences or social circumstances of the woman. But less than 50% of respondents indicated that a doctor should face professional sanctions for performing a termination after 24 weeks’ gestation, even when there is no medical reason for the termination.

One possible explanation for the difference in responses to questions about lawfulness and sanctions is that respondents drew a distinction between legalising abortion and removing sanctions. Respondents with ambivalent attitudes to abortion may favour removal of sanctions but retention of a legal bar on abortion as an intermediate position between full legalisation and full prohibition. This could reflect the prevailing semi-legal status (which was in place until recently in Victoria, and is still in place in most other Australian jurisdictions), where abortion is illegal under at least some laws but professional sanctions are rarely, if ever, enforced.

Another possibility is that respondents may have an in-principle objection to abortion but are more prepared to accept it when they understand the reason, especially if there is a medical reason for abortion. Support for abortion was generally higher when respondents were given greater information about timing and reasons. We speculate that this higher level of support could have been because respondents had a greater ability to identify with women seeking an abortion when contextual information was present, or because respondents thought that the contextual details were morally relevant factors — that is, that they provided moral reasons for allowing abortion. It is possible that, when no context is given, respondents tend to assume there are no significant moral reasons for abortion to proceed.

The sensitivity of Australians’ views on abortion to contextual details may have implications for other debates about ethics. The more permissive attitude elicited when context was provided in our study may, for example, carry over to debates about euthanasia, the use of medicine or technology for human enhancement, organ donation, and embryonic stem cell research. It is an open question whether policy formation should be informed by views about abstract propositions or about cases containing contextual details.

Simple yes/no polls, as used in previous surveys, may give a misleading picture of public opinion, as a simplistic division between “pro-choice” and “anti-abortion” does not accurately reflect the views of Australians. Individuals have nuanced views that depend on the reasons for which women seek abortion. Nonetheless, opinion surveys — no matter how robust — should not dictate policy or law. Policies and laws should be grounded on ethical arguments. We have attempted to provide such arguments, adding to previous discussions of abortion and the law.2,25,26This study has shown that Australians are supportive of both access to abortion, including late abortion in many circumstances, and liberal abortion law reform.

1 Attitudes regarding whether abortion should be lawful during each trimester of pregnancy (effective national sample size, 798)*

First trimester

Second trimester

Third trimester†

Lawful

61%

12%

6%

Unlawful

12%

28%

48%

Depends on the circumstances

26%

57%

42%

Can’t say or don’t know

1%

3%

5%

* Weighted frequencies and cross-tabulations were used to calculate percentages. † Total of percentages is greater than 100% due to rounding.

2 Attitudes regarding whether a doctor should face professional sanctions, including possible deregistration, for performing an abortion after 24 weeks’ gestation (effective national sample size, 798)*

Circumstance†

Should face sanctions

Should not face sanctions

Can’t say

When continuing the pregnancy would involve greater risk to the life of the woman than termination

11%

78%

11%

When there is evidence that the baby is suffering such severe abnormalities that it would be unlikely to survive long after birth and that medical treatment would be unlikely to prolong its life

11%

78%

11%

When continuing the pregnancy would involve greater risk of injury to the physical health of the woman than termination

13%

76%

11%

When the pregnancy was caused by rape or incest

13%

73%

14%

When there is evidence the baby is suffering severe abnormalities that would result in a very serious intellectual or physical impairment

14%

72%

15%

When continuing the pregnancy would involve greater risk of injury to the mental health of the woman than termination

17%

67%

16%

When there is evidence that the baby may be mentally impaired

19%

61%

21%

When there is evidence that the baby may be physically impaired

21%

59%

21%

When the woman has a major drug addiction

22%

58%

20%

When the woman is a minor (aged 15 years or under) and did not realise or admit earlier that she was pregnant

26%

53%

21%

When the woman is a minor (aged 15 years or under)

26%

51%

23%

When the woman’s partner is abusive and is likely to be abusive to the child

33%

39%

27%

When the woman did not realise or admit earlier that she was pregnant

35%

38%

28%

When the woman’s partner died or left her during pregnancy

45%

30%

25%

If, for any reason, the woman decides that she does not wish to have a child at that point in her life

45%

31%

23%

When the woman or family cannot afford to raise the child

42%

30%

28%

* Weighted frequencies and cross-tabulations were used to calculate percentages. † Participants were asked to think specifically about a situation in which they or a woman close to them (eg, partner, sister, daughter or close friend) was facing each circumstance.